How do you do therapy with a three year old… and other random questions about therapy for children.

“How do you do therapy with a three year old?” One concerned and apprehensive parent asked. This isn’t just one parent, this is actually many parents I encounter. Usually a Foster Parent or a parent that is on the fence or opposed to therapy for their child. It is not uncommon for me to respond with “In fact, I have done therapy with children as young as 18 months old.” Then silence followed by a “huh, you can really do that? How does that work?” often met with facial expressions of confusion and disbelief, and then curiosity when I explain how the brain develops and the interventions we can use to work with children this age.

In the rapidly growing age of brain health services, children’s therapy services are being presented to a new and under informed community of parents, teachers, and family members. With the stressful times and changes to our culture since 2020 with the COVID outbreak we have exposed children to very divisive and uncharted conditions that we ourselves were not sure how to navigate. Suicide rates have drastically spiked in children ages 10 and up and in adults. Substance use and abuse has skyrocketed, and countless losses for any number of reasons and conditions have created a feeling of instability and insecurity. With the lapse in education with school closing and alternative environments, we have taught children not to expect anything to be consistent. Anxiety, behavioral issues, school refusal, and depression have increased and teachers are facing more challenging dynamics in their classrooms with a lack of resources to refer families to. During the pandemic many community based providers closed their doors and non-profit organizations had to cut valuable programs they once offered. Children and caretakers that once had a safe haven from domestic abuse and violence were forced to stay in situations they no longer had lifelines out of. The DHHS Protective Services were limited from their typical services and virtual visits and taking peoples word that kids were safe replaced home visits, mandated therapy and participation, random drop-ins, and interventions that typically would have screened for and ruled out ongoing abuse. When the world went on pause for almost two years, the issues and problems behind this didn’t stop and now we are seeing record numbers of parents and caretakers seeking therapy services to treat themselves and their young children.

What does a therapy session look like with a child?

Therapy with kids uses a lot of different techniques and approaches. It is not your traditional “talk” therapy that we have seen depicted on TV shows and movies. Therapy with kids, especially children who are under the age of 8, often require interventions and activities to make therapy engaging, fun, and safe physically and emotionally for them. Painting, drawing, crafts, playing with sand and miniatures, dollhouses and puppets, music. These are all examples of things that we use in therapy with children. Children play what they experience, even really young children who may not have strong verbal skills, or may have communication or verbal delays at an older chronological age do well with these things. It is not uncommon for children to want to bring home their creations or share what they made in the sand with a trusted caretaker. I warn caretakers about this as it has a special meaning to them. Usually when we create in therapy, we are processing and addressing emotions, memories, and experiences the child has had within that creation. It’s very important for caretakers and other adults the child may share these with to know it has a special representation for many kids and the creation should never be criticized, questioned, or judged. It is also important to know that special care should be taken because of this at home and if there is a need to remove it from the home or child’s space, the child has part of the process and can consent to this. Many of these creations may not look like much to others, but they are very meaningful for the child. It’s best to not assume that if something is ripped, broken or faded that it is okay to discard it. I often will suggest that a caretaker purchase a small tub, box or folder for the child to keep their special items if they cannot be on display or they need to be put away.

How do I make sure my child is using therapy properly?

This is a great question, and so many caretakers are confused on what therapy really looks like and what to expect. It really depends on the temperament of the child, if they have had therapy before, and the reason they are presenting for therapy. Children react to the responses of their caregivers, they look for signals on if something is okay or not. If a caretaker is anxious and unsure of a professional, that child typically will take on a guarded or apprehensive approach. If the caretaker is open, comfortable and engaging, the child will typically see that person as safe to be around. If the child is pushed too hard to “talk” by a caregiver, they will come in to therapy shut down and refuse to share. The attitude and presentation of a caretaker are very important to developing a good rapport from the start. On average it is suggested from researchers in the field that it takes approximately 10-20 sessions for a child to develop a strong therapeutic bond and relationship with the therapist. It all depends on their prior experiences, if any, and the environment and trust level with their caretakers. This is often frustrating if there are major behavioral issues and concerns that the caretaker is wanting therapy to address because it may be perceived that therapy is not “working” or the therapist is bad at their job. Realistically there is no “exact” way a child will react to a therapist. It is not uncommon if children are wanting and craving someone to talk to about things bothering them that within the first couple of sessions they spill everything. Some kids come in to therapy with an understanding of how to use their time and are desperate to tell their story. Others are distrustful, especially if they have a parent or caregiver that has urged or suggested that they or the caretaker will get in trouble if the child talks about personal stuff. These are the hardest situations that may take 6 months to a year to develop a good relationship for the child to finally trust the therapist. This is also very typical if a child has changed therapists several times. As a final tip: Never threaten telling on the child to the therapist as a form of redirection. This causes distrust in the therapy relationship and will cause the child to fear the therapist as a disciplinarian. Plus it gives away your authority that you want to maintain.

I don’t think therapy is working. I don’t see a difference in their behavior and it actually got worse!

This is a tough one for parents. Especially if they have not had therapy as a child themselves or as adults to have a template and understanding of what therapy is. Therapy is a brain health treatment service to process experiences, emotions, reactions, and sometimes trauma. I cannot take away someones trauma or experiences and make them forget. I can only help them understand it differently to make it less distressing. Sometimes as we work through these things our behavior and anxiety reduces and there is a positive indicator of decreased undesirable behavior at home. However it is very common, especially in children with trauma, for therapy to trigger behavior and other issues temporarily. Because we are sometimes talking about and working on tough experiences that may trigger certain emotions, the child has to learn through therapy how to contain and experience the feelings so they lose intensity, and influence. This is not something that happens within our 45 minutes together, it happens outside of therapy, and through subsequent sessions afterwards.

It is not uncommon for a caretaker to place a child in therapy for the therapist to “fix them” or to address behavior problems. Therapy does not fix you, and it does not fix behavior. Therapy teaches a child, or adult, to cope, to feel safe, to identify triggers, to process feelings and experience them safely, to identify relationship patterns and attachments, to lessen the burden of stress and self judgement. A common misconception is that therapy will get rid of undesirable or bad behavior. I see this a lot with children who have been involved with the protective services system, that a child’s behavior is a reaction to another person’s poor choices, an environmental trigger, or other issue that the child literally has no control to change, yet we blame the child for reacting. It is very common for me to see caretakers blame or scapegoat children who are reacting to poor parenting decisions, abuse, and other factors that the caretakers, teachers, daycare workers, or others in their life continue to perpetuate. Therapy is not intended to deprogram a child’s healthy reactions to others poor choices and environments. Often times the caretakers and institutions require just as much work as the child does to make the connection and relationship amenable. There is rarely a child client I work with that doesn’t eventually pull the curtain back to show others behavior and discipline strategies as the real issue. Keep this mantra in mind “Behavior is communication”.

What type of information will you tell me? I want to know what is being talked about.

This is such a common questions by caretakers, protective service workers, and other professionals. This is a catch twenty-two for children in therapy. As a child and having a legal guardian, the caretaker does have some reason to ask for information and progress of the services. But the problem with this is the child needs to trust me. If I share everything that is talked about in session with their caretakers that defeats the purpose of therapy. Ethically, I really cannot share anything unless the child and I agree on what content can and will be shared, or it is a life threatening issue where their physical, mental, or emotional safety is at risk. Many anxious caretakers present with the child and want to know all the details so the adult can tell “their side of things”. I want to emphasize here that I do believe it is important for caregivers to be involved in therapy services with the child and to share their observations, however for the purpose of the therapy relationship in this context it is my goal in working individually with a child to support their needs and position. This is where I draw a very strong boundary and is really hard for adults and caretakers to understand. It isn’t that I don’t know the child may be telling me things that are untruthful, minimizing their actions or role, or that I am going to blindly agree without objectivity (some therapists make the mistake of doing this). I need the caretaker to trust that I know these things are happening, that I have good judgement, and I have been well trained to assess and look for these opportunities in a child’s story, and the skill to address things therapeutically.

Why are you making me do therapy? My child is the one with the issue.

This can be confusing. Because I take what is called a “family systems” approach to individual therapy. When working with children, one of the many aspects that is different is the inclusion of caretakers and family members at times to address issues and educate those caring for the child. Because children are not autonomous legally and do not developmentally have the capacity to meet their own needs the caretakers are a big influence on a child’s brain health and the support they need to handle difficult emotions and situations. This means the family will have to participate at times in sessions with the child, or what we call parent consultation and education sessions where it is the adults or caretakers without the child.

Most parents become frustrated hearing all the things they are doing wrong in parenting. This is not what this is intended for. These sessions are to support the things that are going well, and to provide education and training on what to do versus what not to do. Isn’t that one of the biggest frustrations about parenting books and self help? We often get told what not to do, but no one takes a moment to replace that with the things we are supposed to be doing.

A lot of therapists that work with children only focus individually on the child and miss wonderful opportunities to integrate the caretakers and provide valuable information and feedback that supports the goals they are working on with the child. This is unfortunate and is a huge loss in supporting the child.

I know my child has trauma, why won’t they just talk about it?

This is a frustrating part of therapy. Often when I hear this it tells me the caregiver is really worried and wants their child to share about some important or big experience. Children communicate differently than adults do. Because their brains are still developing at a rapid rate and have a lot of work to do, they don’t process information the same as adults. Children may have experiences that would seem severely traumatizing and disastrous to adults and not have the intense reaction and adult does. This is because the child may not know what happened was bad or traumatizing. Or they may not understand how serious it was. It may be a situation where the child is blocking out the experience for self preservation and normal brain protective responses until they are in a place to process it. It can sometimes take years for children to want to talk about or work on an issue an adult would want to address immediately. Just because the adults find the situation urgent or distressing, does not mean the child does and is ready to confront things. Sometimes children are adults before they are in a place to process an experience as a child. Sometimes they never have to process it, because although it seems scary to us, doesn’t mean it was to the child.

Children also do not need to talk about the gritty details of something terrible to process through it. It’s just how their brains work. Often times being allowed a safe space to express and experience their emotions and talk about those versus the actual details of an event is healing enough. Having safe adults that can co-regulate (let the children borrow their calm when upset) is very therapeutic.

I have important updates to tell you, how do you want me to share it?

I cannot emphasize enough how appreciative I am when I have caretakers that want to engage and provide feedback about a child I am working with. Because in reality, I’m really working with the family unit with the child, not just the child. However we want to make a safe space for the child to trust that the therapist does not have a bias or thinks poorly of them due to information that was shared just before or after session. I strongly support the use of email to share with me events or observations for therapy. This allows me to filter through the information for points to touch on. Caretakers talking about behavior in front of the child is an act of shaming, even if it is with the best of intentions or concern. Think about it, when you were a kid it was gut wrenching to listen to a teacher or your caretaker share an embarrassing moment or an incident you were sorry about in front of you and about you to others. It makes you feel like that person is going to change their opinion of you or no longer like you. It breaks trust. Parent consultation sessions are also a great opportunity to share as long as the child is not in a place to hear you talk about them.